Expiratory flow limitation and intrinsic positive end-expiratory pressure in obesity

Breathing at very low lung volumes might be affected by decreased expiratory airflow and air trapping. Our purpose was to detect expiratory flow limitation (EFL) and, as a consequence, intrinsic positive end-expiratory pressure (PEEPi) in grossly obese subjects (OS). Eight OS with a mean body mass index (BMI) of 44 +/- 5 kg/m2 and six age-matched normal-weight control subjects (CS) were studied in different body positions. Negative expiratory pressure (NEP) was used to determine EFL. In contrast to CS, EFL was found in two of eight OS in the upright position and in seven of eight OS in the supine position. Dynamic PEEPi and mean transdiaphragmatic pressure (mean Pdi) were measured in all six CS and in six of eight OS. In OS, PEEPi increased from 0.14 +/- 0.06 (SD) kPa in the upright position to 0.41 +/- 0.11 kPa in the supine position (P < 0.05) and decreased to 0.20 +/- 0.08 kPa in the right lateral position (P < 0.05, compared with supine), whereas, in CS, PEEPi was significantly smaller (<0.05 kPa) in each position. In OS, mean Pdi in each position was significantly larger compared with CS. Mean Pdi increased from 1.02 +/- 0.32 kPa in the upright position to 1.26 +/- 0.17 kPa in the supine position (not significant) and decreased to 1. 06 +/- 0.26 kPa in the right lateral position (P < 0.05, compared with supine), whereas there were no significant changes in CS. We conclude that in OS 1) tidal breathing can be affected by EFL and PEEPi; 2) EFL and PEEPi are promoted by the supine posture; and 3) the increased diaphragmatic load in the supine position is, in part, related to PEEPi.     

Heavy snoring with upper airway resistance syndrome may induce intrinsic positive end-expiratory pressure

We studied eight heavy snorers with upper airway resistance syndrome to investigate potential effects of sleep on expiratory airway and lung resistance, intrinsic positive end-expiratory pressure, hyperinflation, and elastic inspiratory work of breathing (WOB). Wakefulness and non-rapid-eye-movement sleep with high- and with low-resistance inspiratory effort (H-RIE and L-RIE, respectively) were compared. No differences in breathing pattern were seen across the three conditions. In contrast, we found increases in expiratory airway and lung resistance during H-RIE compared with L-RIE and wakefulness (56 +/- 24, 16 +/- 4, and 11 +/- 4 cmH2O . 1(-1) . s, respectively), with attendant increases in intrinsic positive end-expiratory pressure (5.4 +/- 1.8, 1.4 +/- 0.5, and 1.3 +/- 1.3 cmH2O, respectively) and elastic WOB (6.1 +/- 2.2, 3.7 +/- 1.2, and 3.4 +/- 0.7 J/min, respectively). The increase in WOB during H-RIE is partly caused by the effects of dynamic pulmonary hyperinflation produced by the increased expiratory resistance. Contrary to the Starling model, a multiple-element compliance model that takes into account the heterogeneity of the pharynx may explain flow limitation during expiration.     

鼻塞持续气道正压通气在早产儿低氧血症中的应用及护理

新生儿低氧血症是呼吸功能障碍时的常见表现,可由通气/换气中任何环节的障碍所致.严重者伴有组织缺氧,导致细胞代谢和器官功能障碍,甚至威胁生命.新生儿脑细胞对缺氧很敏感,持续严重缺氧常发生不可逆的损伤.川新生儿出现呼吸功能障碍及低氧血症时,除积极治疗原发病外,适当增加供氧提高肺泡氧分压,配合机械通气以改善通换气功能等方法.     

Assessment of cardiac filling pressure during continuous positive pressure ventilation

Before and after 10 dogs were near-drowned with fresh water, cardiac filling pressures were measured during spontaneous respiration, controlled mechanical ventilation with ambient expiratory airway pressure, continuous positive-pressure ventilation (CPPV) with 20 ml H2O PEEP, and CPPV alone. Pulmonary arterial occlusion and left ventricular end diastolic pressures were measured and compared. Intrapleural pressure was subtracted from values for each of these pressures to calculate respective transmural filling pressures. Mechanical ventilation and CPPV each decreased thoracic venous return, but only CPPV increased pulmonary arteriolar resistance. The increase of both airway pressure and pulmonary arteriolar resistance, in turn, increased both right atrial and pulmonary arterial occlusion pressures, but decreased left ventricular filling. Thus, measurement of pulmonary arterial occlusion pressure alone did not allow accurate assessment of cardiac filling pressure. The authors found that measurement of intrapleural pressure was necessary to obtain an accurate reflection of left ventricular filling pressure during CPPV. Momentary interruption of CPPV to measure any pressure was of no value in assessing vascular filling and caused pulmonary edema in several animals. Therefore, the authors recommend that vascular pressures be measured and evaluated without interruption of positive airway pressure.     

Differential effects of nasal continuous positive airway pressure on reversible or fixed upper and lower airway obstruction

Our study was to assess whether there were differential effects of nasal continuous positive airway pressure (nCPAP) on different kinds of obstruction in either upper or lower airways in patients with chronic obstructive pulmonary disease (COPD). nCPAP (6 cmH2O for ten minutes) was applied to 7 patients with reversible extrathoracic upper airway obstruction (RUAO) and 3 patients with fixed extrathoracic upper airway obstruction (FUAO). Eighteen stable asthmatics, receiving methacholine challenge to induce a more than 20% reduction in FEV1, were randomly investigated for the effect of nCPAP or sham pressure on reversible lower airway obstruction. Nine stable COPD patients were enrolled to study the effect on irreversible lower airway obstruction. Maximal expiratory and inspiratory flow volume curves and dyspnoea scores were obtained before and after immediate withdrawal of nCPAP. In the RUAO group, nCPAP significantly improved stridor and dyspnoea scores, decreased the ratio of FEF50/FIF50 from 2.05 +/- 0.25 to 1.42 +/- 0.16, and increased peak inspiratory flow (PIF) as well as forced inspiratory vital capacity by 26 +/- 8% and 9 +/- 4%, respectively. In expiratory phase, there was no significant change in pulmonary functions. In asthmatics, nCPAP significantly reversed methacholine-induced bronchoconstriction increasing forced vital capacity by 10 +/- 3%, FEV1 by 15 +/- 4% and PIF by 32 +/- 11%. nCPAP significantly increased the response to bronchodilators. The improvement in airflow rate persisted for at least 5 min after nCPAP withdrawal and was highly correlated with the response to bronchodilators. There was no significant effect of nCPAP on airflow rate in COPD patients. Subjective dyspnoea score changes paralleled the pulmonary function improvement. We conclude that there are differential effects of nCPAP on airflow rates in patients with different nature of airway obstruction. Patients with airway obstruction caused by structural changes may not benefit from the use of nCPAP in improving airflow rates.     

Tracheal pressure triggering a demand-flow continuous positive airway pressure system decreases patient work of breathing

OBJECTIVES: Triggering a ventilator "ON" at the carinal end of the endotracheal tube decreases imposed work of breathing by bypassing the resistance imposed by the breathing circuit and the endotracheal tube. We compared work of breathing during spontaneous ventilation between three methods of triggering the ventilator "ON": a) conventional pressure triggering from inside the ventilator; b) flow-by triggering; or c) tracheal pressure triggering at the carinal end of the endotracheal tube. We hypothesized that the work of breathing would be substantially decreased with tracheal pressure triggering compared with conventional pressure and flow-by methods in patients receiving continuous positive airway pressure. DESIGN: Clinical, prospective study. SETTING: University teaching hospital. PATIENTS: Fourteen adults diagnosed with acute respiratory failure. INTERVENTIONS: All patients were breathing spontaneously at an FIO2 of 0.30 to 0.40 and received 5 cm H2O of continuous positive airway pressure. Three different methods of triggering the ventilator while set in the continuous positive airway pressure mode were administered in random order. MEASUREMENTS AND MAIN RESULTS: Real-time measurements of esophageal pressure and tidal volume were integrated with a respiratory monitor (CP-100, Bicore, Riverside, CA) that uses the Campbell diagram to calculate total work of breathing. Imposed work of breathing was calculated by integrating tidal volume with the pressure at the carinal end of the endotracheal tube. Physiologic work of breathing was calculated by subtracting imposed work of breathing from the total work of breathing. Breathing frequency, the index of rapid shallow breathing (breathing frequency/tidal volume), peak inspiratory flow rate demand, exhaled minute ventilation, and the duration of respiratory muscle contraction assessed by the ratio of inspiratory time to total cycle time were also measured. Data were analyzed by Friedman's repeated-measures analysis of variance on ranks. Alpha was set at .05 for statistical significance. Imposed work of breathing decreased to approximately zero during tracheal pressure triggering. As a result, total work of breathing decreased by approximately 40% compared with the flow-by and conventional methods. During tracheal pressure triggering only, airway pressure increased above baseline pressure to approximately 11 cm H2O, which resembled pressure-support ventilation. Also, during tracheal pressure triggering, tidal volume and peak inspiratory flow rate were significantly increased, while the pressure-time product and the index of rapid shallow breathing were significantly decreased. Hemodynamic status and oxygen saturation were not clinically affected. CONCLUSIONS: The tracheal pressure triggering of a demand-flow continuous positive airway pressure system creates an effect similar to pressure-support ventilation that significantly decreases imposed work of breathing and, thus, total work of breathing. We recommend moving the triggering site of the ventilator to the carinal end of the endotracheal tube.     

Reversal of sinus arrest and atrioventricular conduction block in patients with sleep apnea during nasal continuous positive airway pressure

Sinus arrest and atrioventricular (AV) block have been demonstrated in as much as 30% of patients with sleep apnea (SA). The reversal of heart block after tracheostomy has been shown. Nasal continuous positive airway pressure (nCPAP) now is widely used as the treatment of SA, but little data are available on the effect of nCPAP on heart block in patients with SA. During a 17-mo period 239 patients were found to have SA in an ambulatory study. Heart block was identified in 17 (16 male, one female) of these patients. Standard polysomnography and two-channel long-term ECG before and during nCPAP therapy were performed in order to assess the effect of nCPAP on SA and heart block. Mean age of the 17 patients was 50.7 yr (range, 27 to 78 yr), mean respiratory disturbance index (RDI) was 90/h (SD +/- 36.1) before nCPAP and 6/h (SD +/- 6.2) on the second treatment night. The number of episodes of heart block during sleep decreased significantly (p < 0.001) from 1,575 before therapy to 165 during nCPAP. In 12 patients (70.6%) heart block was totally prevented by nCPAP. In another three patients, there was a 71 to 97% reduction in the number of episodes of heart block on the second treatment night, and in two of them a complete reversal occurred thereafter. Two patients exhibited an increase in block frequency during nCPAP, which was reversed after 4 wk of nCPAP in one but persisted in the other.(ABSTRACT TRUNCATED AT 250 WORDS)     

Work of breathing, inspiratory flow response, and expiratory resistance during continuous positive airway pressure with the ventilators EVITA-2, EVITA-4 and SV 300

A sensor plasmid was constructed by inserting the regulation unit from the cadA determinant of plasmid pI258 to control the expression of firefly luciferase. The resulting sensor plasmid pTOO24 is capable of replicating in Gram-positive and Gram-negative bacteria. The expression of the reporter gene as a function of added extracellular heavy metals was studied in Staphylococcus aureus strain RN4220 and Bacillus subtilis strain BR151. Strain RN4220(pTOO24) mainly responded to cadmium, lead and antimony, the lowest detectable concentrations being 10 nM, 33 nM and 1 nM respectively. Strain BR151(pTOO24) responded to cadmium, antimony, zinc and tin at concentrations starting from 3.3 nM, 33 nM, 1 microM, and 100 microM, respectively. The luminescence ratios between induced and uninduced cells, the induction coefficients, of strains RN4220(pTOO24) and BR151(pTOO24) were 23-50 and about 5, respectively. These results were obtained with only 2-3 h incubation times. Freeze-drying of the sensor strains had only moderate effects on the performance with respect to sensitivity or induction coefficients.     

Cerebral hemodynamic changes in sleep apnea syndrome and effect of continuous positive airway pressure treatment

BACKGROUND AND OBJECTIVE: A clear association among snoring, sleep apnea, and increased risk of stroke has been shown by previous studies. However, the possible role played by sleep apnea in the pathogenesis of cerebrovascular disease is subject to debate. To evaluate the influence of hemodynamic changes caused by obstructive sleep apnea syndrome (OSAS), we investigated cerebrovascular reactivity to hypercapnia in patients with OSAS. METHODS: The study was performed at baseline and after 1 night and 1 month of nasal continuous positive airway pressure (n-CPAP) therapy, with patients in the waking state (8:00 to 8:30 AM and 5:30 to 6:00 PM) with transcranial Doppler ultrasonography. Cerebrovascular reactivity was calculated with the breath-holding index (BHI). RESULTS: In the baseline condition, compared with normal subjects, patients with OSAS showed significantly lower BHI values in both the morning (0.57 versus 1.40, p < 0.0001) and the afternoon (1.0 versus 1.51, p < 0.0001). Cerebrovascular reactivity was significantly higher in the afternoon than it was in the morning in both patients (p < 0.0001) and controls (p < 0.05). In patients, the BHI returned to normal values, comparable with those of control subjects, after both 1 night and 1 month of n-CPAP therapy. CONCLUSIONS: These findings suggest an association between OSAS and diminished cerebral vasodilator reserve. This condition may be related to the increased susceptibility to cerebral ischemia in patients with OSAS, particularly evident in the early morning.     

Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep Apnea/Hypopnea syndrome

The minimal disease severity at which patients with the sleep apnea/hypopnea syndrome (SAHS) gain benefit from treatment is not well characterized, although a pilot study of continuous positive airway pressure (CPAP) therapy showed daytime improvements in patients with 5 to 15 apneas + hypopneas per hour slept (AHI). We have thus performed a second, larger, randomized, placebo- controlled study in a prospective series of 34 patients (13 female) with mild SAHS (AHI 5 to 15) and daytime sleepiness. Patients spent 4 wk on CPAP treatment and 4 wk on an oral placebo, with randomization of treatment order, and daytime assessments on the last day of each treatment. Effective CPAP use averaged 2.8 +/- 2.1 h (mean +/- SD) per night. Compared with placebo, CPAP improved symptom score (p < 0.01), subjective (Epworth; p < 0.01) but not objective (maintenance of wakefulness test; p > 0.2) sleepiness, performances on 2 of 7 cognitive tasks (p < 0.02), depression score (p < 0.01), and five subscales of the SF-36 health/functional status questionnaire (p 相似文献   

Acute effects of nasal continuous positive airway pressure on 24-hour blood pressure and catecholamines in patients with obstructive sleep apnea

OBJECTIVE: To estimate the risk for spina bifida associated with the common mutation C677T of the MTHFR gene in a country with a relatively low prevalence of NTDs. DESIGN: Case-control study. SUBJECTS: Cases: 203 living patients affected with spina bifida (173 myelomeningocele and 30 lipomeningocele); controls: 583 subjects (306 young adults and 277 unselected newborns) from northern and central-southern Italy. SETTING: Cases: three spina bifida centres; young adult controls: DNA banks; newborn controls: regional neonatal screening centres. MAIN OUTCOME MEASURES: Prevalence of the C677T genotypes in cases and controls by place of birth; odds ratios for spina bifida and estimated attributable fraction. RESULTS: The prevalence of T/T, T/C, and C/C genotype was 16.6%, 53.7%, and 29.7% in controls and 25.6%, 43.8%, and 30.6% in cases, respectively. We found no differences between type of defect or place of birth. The odds ratio for spina bifida associated with the T/T genotype v C/C plus T/C was 1.73 (95% CI 1.15, 2.59) and the corresponding attributable fraction was 10.8%. No increased risk was found for heterozygous patients (OR=0.79, 95% CI 0.53-1.18). CONCLUSION: This study, as well as the meta-analysis we updated, shows that homozygosity for the MTHFR C677T mutation is a moderate risk factor in Europe, and even in Italy where there is a relatively low prevalence of spina bifida. The estimated attributable fraction associated with this risk factor explains only a small proportion of cases preventable by periconceptional folic acid supplementation. Thus, other genes involved in folate-homocysteine metabolism, their interaction, and the interaction between genetic and environmental factors should be investigated further.     

Abnormal autonomic stress responses in obstructive sleep apnoea are reversed by nasal continuous positive airway pressure

Obstructive sleep apnoea (OSA) is associated with abnormalities in autonomic stress tests, which are tests of cardiovascular response in the autonomic nervous system (ANS). The level of abnormality has been related to the level of overnight arterial oxygen saturation (Sa,O2). We have studied ANS function pre- and post-treatment with nasal continuous positive airway pressure (nCPAP) in six males with moderately severe or severe OSA (apnoea/hypopnoea index (AHI) median 51 (range 14-74 events.h-1 of sleep). Tests consisted of heart rate responses to Valsalva manoeuvre, deep breathing, and change of posture from lying to standing. In addition, systolic blood pressure (SBP) response to standing and diastolic blood pressure (DBP) response to handgrip were studied. Each abnormal test (compared to published normal values) scored +1.0 and each marginal test result (90-95% confidence interval for normals) scored +0.5. A total score was calculated for the five tests performed in the evening and morning (maximum score 10 per patient). Patients had been receiving treatment for more than 1 year (median 471 (389-624) days) and objective compliance was monitored by a clock counter in the nCPAP machines. Five of six patients had regularly used nCPAP (mean 7.8 h.night-1) and all showed a normalization in ANS test score: pre-nCPAP 2 (1-4.5), post-nCPAP 0.2 (0-0.5) (p < 0.05, Wilcoxon signed rank test). One poorly compliant subject (No. 6; nCPAP 3 h.night-1) had a deterioration in ANS test score: 1 pre-nCPAP to 1.5 post-nCPAP. The improvement in ANS test score in the five compliant patients was positively correlated with an improvement in mean Sa,O2 during sleep posttreatment. We conclude that successful treatment of obstructive sleep apnoea leads to normalization of impaired autonomic stress responses.     

Spontaneous platelet activation and aggregation during obstructive sleep apnea and its response to therapy with nasal continuous positive airway pressure. A preliminary investigation

STUDY OBJECTIVE: To determine whether alterations of platelet reactivity occur during obstructive sleep apnea (OSA) and, if so, whether therapy with nasal-continuous positive airway pressure (N-CPAP) alters this reactivity. DESIGN: Patients with suspected moderate to severe OSA had blood drawn for spontaneous platelet aggregation (sAGG) and activation (sACT) measurements at hourly intervals during diagnostic polysomnography (PSG) and, in those with confirmed OSA, on a separate night during which N-CPAP was applied. SETTING: Tertiary care center sleep laboratory. PATIENTS: Six patients with OSA had matched blood samples drawn on both diagnostic and N-CPAP treatment nights. Five patients without confirmed OSA served as controls. INTERVENTIONS: N-CPAP was applied to those patients with OSA and pressures adjusted with goals of eliminating apneas; N-CPAP was then maintained through the night. MEASUREMENTS AND RESULTS: sACT and sAGG were measured using flow cytometric determination of P-selectin expression using a monoclonal antibody. Platelet aggregation was assessed by measuring the proportion of platelets larger than resting platelets by light scatter techniques. Mean values for sACT and sAGG were higher on the diagnostic night compared with treatment night (p = 0.001 and p = 0.003, analysis of variance, respectively). The mean baseline supine sACT compared with completion supine sACT for both diagnostic and N-CPAP nights also revealed significant differences (mean = 16.6 +/- 3.5% vs 36.9 +/- 7.5%, p = 0.04; and 11.9 +/- 3% vs 39.5 +/- 9.1%, p = 0.04). Platelet activation during sleep in five subjects without OSA resembles that found in patients with OSA during N-CPAP. CONCLUSIONS: Increased platelet sACT and sAGG occur during sleep in patients with OSA. This effect is greatly reduced by N-CPAP.     

Randomised trial of elective continuous positive airway pressure (CPAP) compared with rescue CPAP after extubation

AIM: To determine if a weaning regimen on flow driver continuous positive airway pressure (CPAP) would decrease the number of ventilator days but increase the number of CPAP days when compared with a rescue regimen. METHODS: Fifty eight babies of 24-32 weeks gestation with respiratory distress syndrome (RDS) were studied prospectively. After extubation they were randomly allocated to receive CPAP for 72 hours (n = 29) according to a weaning regimen, or were placed in headbox oxygen and received CPAP only if present "start CPAP" criteria were met (n = 29, rescue group). RESULTS: There was no difference in successful extubation at 72 hours, 1 and 2 weeks, between the groups in terms of the number of reventilation episodes, reventilation days, or in total days of CPAP. Birthweight, gestational age, race, day of first extubation, antenatal or postnatal steroids, patent ductus arteriosus status and maximal mean airway pressure used were of no value in predicting success or failure at 72 hours, 1, or 2 weeks. CONCLUSION: The weaning regimen did not decrease the number of ventilator days or days on CPAP compared with the rescue regimen. The rescue regimen on flow driver CPAP seems to be a safe and effective method of managing a baby of 24-32 weeks gestation who has been ventilated for RDS or immature lung disease.     

Effects of nasal continuous positive airway pressure therapy on respiratory parameters of upper airway patency in patients with obstructive sleep apnea syndrome

OBJECTIVES: To assess whether an initial treatment with nasal continuous positive airway pressure (NCPAP) therapy, applied for one night, had any effect on airway patency. METHODS: In 18 patients with obstructive sleep apnea syndrome (OSAS), we measured the total resistance of the respiratory system (Rrs) and their relevant lung functions before and after polysomnography, with and without NCPAP therapy. The Rrs was measured at 3 Hz with the forced oscillation technique. The overnight changes in the specific respiratory conductance (SGrs=reciprocal of the Rrs per unit lung volume) was also calculated in the sitting position. Since many reports have suggested that obesity, through fat deposits around the pharynx, can affect the mechanical and neuromuscular properties of the upper airway, we also investigated if the degree of obesity was related to the magnitude of improvement in these parameters. RESULTS: After the first night of NCPAP therapy, the Rrs decreased (sitting: 4.8+/-0.4 vs 4.3+/-0.4 cm H20/L/s, p < 0.05; lying: 6.5+/-0.4 vs 5.6+/-0.4 cm H20/L/s, p < 0.05) and the maximal voluntary ventilation increased in the morning (sitting: 101.6+/-5.8% vs 106.4+/-4.5%, p < 0.05; lying: 91.2+/-5.4% vs 97.9+/-4.7%, p < 0.05). The overnight difference in the SGrs showed a significant improvement after the initial treatment with NCPAP therapy (p < 0.05). However, the lung volume, flow volume loop, and closing volume in the morning did not change significantly after the therapy. An overnight decrease in the Rrs following NCPAP therapy is significantly correlated with the body mass index (sitting: r=0.54, p < 0.05; lying: r=0.61, p < 0.01). CONCLUSION: The improvements in Rrs without changes in spirometry may reflect improved upper airway patency after NCPAP therapy. The degree of obesity is suggested to be associated with the treatment effect on upper airway in patients with OSAS.     

Effects of continuous positive airway pressure on obstructive sleep apnea and left ventricular afterload in patients with heart failure

BACKGROUND: The objectives of this study were to determine the effects of continuous positive airway pressure (CPAP) on blood pressure (BP) and systolic left ventricular transmural pressure (LVPtm) during sleep in congestive heart failure (CHF) patients with obstructive sleep apnea (OSA). In CHF patients with OSA, chronic nightly CPAP treatment abolishes OSA and improves left ventricular (LV) ejection fraction. We hypothesized that one mechanism whereby CPAP improves cardiac function in CHF patients with OSA is by lowering LV afterload during sleep. METHODS AND RESULTS: Eight pharmacologically treated CHF patients with OSA were studied during overnight polysomnography. BP and esophageal pressure (Pes) (ie, intrathoracic pressure) were recorded before the onset of sleep and during stage 2 non-rapid eye movement sleep before, during, and after CPAP application. OSA was associated with an increase in systolic BP (from 120.4+/-7.8 to 131.8+/-10.6 mm Hg, P<0.05) and systolic LVPtm (from 124.4+/-7.7 to 137.2+/-10.8 mm Hg, P<0.05) from wakefulness to stage 2 sleep. CPAP alleviated OSA, improved oxyhemoglobin saturation, and reduced systolic BP in stage 2 sleep to 115.4+/-8.5 mm Hg (P<0.01), systolic LVPtm to 117.4+/-8.5 mm Hg (P<0.01), heart rate, Pes amplitude, and respiratory rate. CONCLUSIONS: In CHF patients with OSA, LV afterload increases from wakefulness to stage 2 sleep. By alleviating OSA, CPAP reduces LV afterload and heart rate, unloads inspiratory muscles, and improves arterial oxygenation during stage 2 sleep. CPAP is a nonpharmacological means of further reducing afterload and heart rate during sleep in pharmacologically treated CHF patients with OSA.     

Effects of nasal continuous positive airway pressure on breathing pattern and respiratory drive in patients with obstructive sleep apnea syndrome

To examine the influence of continuous positive airway pressure (CPAP) therapy on respiratory center drive in patients with obstructive sleep apnea syndrome (OSAS), 20 normocapnic OSAS patients (group 0) and 20 simple snoring patients were studied. In the first night, diagnostic polysomnography (PSG) was performed. Before and after PSG monitoring, mouth occlusion pressure (P0.1), tidal volume (VT), minute ventilation (VE), respiratory rate (RR), inspiratory time (Ti), expiratory time (Te), total cycle duration (Ttot), inspiratory duty cycle (Ti/Ttot), mean inspiratory flow (VT/Ti) and effective inspiratory impedance (P0.1/VT/Ti, Ieff) were measured while they were breathing room air. In the following night the OSAS patients were treated with nasal CPAP and PSG monitoring and the above mentioned measurements were repeated. The results showed that pre-PSG values of P0.1, RR and P0.1/VT/Ti in the OSAS patients were significantly higher than those in the snoring patients, while VT, Ti, Te and Ttot values were lower. In the first night, the post-PSG P0.1 value in the OSAS patients increased markedly as compared with the pre-PSG. After overnight nasal CPAP therapy, the respiratory disorder index in the OSAS patients decreased markedly, the nadir SaO2 increased markedly, but the post-PSG P0.1 value did not increase significantly. It is concluded that, before sleep, OSAS patients exhibit a higher respiratory drive and a shallow and frequent breathing pattern as compared with simple snoring patients. After nocturnal sleep, the respiratory drive of OSAS patients increases significantly, the breathing pattern becomes more shallow and frequent. Nasal CPAP may effectively relieve the sleep apnea and hypopnea as well as the resulting hypoxemia and therefore correct the changes in breathing pattern and respiratory drive through nocturnal sleep in patients with OSAS.     

Long-term evolution of daytime somnolence in patients with sleep apnea/hypopnea syndrome treated by continuous positive airway pressure

We demonstrated in a previous study that excessive daytime sleepiness (EDS) in patients who have sleep apnea/hypopnea syndrome (SAHS) and are undergoing continuous positive airway pressure (CPAP) treatment improved differently in two groups of patients: in group I, multiple sleep latency tests (MSLT) were normalized after 50 days of treatment (individual value > 10 minutes), whereas they remained low (individual value < 10 minutes) in group II, with a significant difference between groups. To evaluate the long-term evolution of daytime somnolence under nasal CPAP treatment, five patients from group I and seven patients from group II underwent a new polysomnography and MSLT 4 years after the previous study. Clinical, polysomnographic and MSLT results obtained at baseline before treatment (T1), after the initial 50-day period of CPAP treatment (T2), and after 4 years (T3) were compared. The significant difference in mean MSLT value between the two groups previously observed at T1 and T2 disappeared at T3 (group I: 12.4+/-5.9 minutes; group II: 9.7+/-5.9 minutes). We found that this long-term improvement in excessive daytime somnolence was independent of the initial MSLT value, the severity of SAHS, and the initial MSLT changes under nasal CPAP. Long-term MSLT evolution was significantly correlated to CPAP compliance. These results demonstrate that even in the absence of a significant increase in MSLT at the beginning of CPAP treatment, further improvement is still possible several years later, which may encourage the regular, long-term use of nasal CPAP by patients.